Provider Demographics
NPI:1073543716
Name:RENZAGLIA, GARY JOHN (PHD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:JOHN
Last Name:RENZAGLIA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 9TH ST
Mailing Address - Street 2:ROOM 150 FISCAL ALLOCATIONS AND ESTIMATES UNIT
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95814-6414
Mailing Address - Country:US
Mailing Address - Phone:916-651-9475
Mailing Address - Fax:916-651-8908
Practice Address - Street 1:10333 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422-5808
Practice Address - Country:US
Practice Address - Phone:805-468-2000
Practice Address - Fax:805-468-6011
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10484103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling